Failure to Discontinue and Accurately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to provide proper pharmaceutical services, resulting in a resident receiving Hydrocodone-Acetaminophen (Norco) after it had been discontinued following a hospital visit. The medication was not discontinued in the resident's chart, and the resident received Norco more frequently than the order allowed. Documentation showed that the resident was administered Norco two hours apart instead of the prescribed six-hour interval, and the medication was not properly documented in the electronic Medication Administration Record (eMAR), leading to a double dosing incident. The resident involved was an elderly female with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, dependence on dialysis, and chronic embolism and thrombosis. She was cognitively impaired and required assistance with activities of daily living. After returning from the hospital, her discharge instructions included discontinuation of Norco, but this was not reflected in her medication orders at the facility. As a result, she received Norco doses inappropriately, which was noted by staff when she became lethargic, drowsy, and experienced nausea and vomiting. Her condition deteriorated throughout the day, and she was eventually transported to the hospital, where she expired from cardiac arrest. Interviews and record reviews revealed that staff failed to reconcile hospital discharge orders with the facility's medication records, did not discontinue the medication in the system, and did not document administration properly in both the eMAR and narcotic log. There was confusion among staff regarding the resident's medication orders, and the lack of proper documentation and communication led to the administration of a discontinued and potentially harmful medication. The facility's policies required proper documentation and reconciliation of medication orders, but these were not followed, resulting in a critical medication error.